Welcome back to Open Minded Health Promotion! This week we’re looking at health promotion for transgender men and individuals assigned female at birth. Depending on your history some of these tips will apply more or less to you.

Please remember that these are specific aspects of health in addition to the standard recommendations for everyone (e.g., colonoscopy at age 50). Based on your health and your history, your doctor may have different recommendations for you. Listen to them.

All transgender men should consider…

Talk with their doctor about their physical and mental health

Practice safer sex where possible. Sexually transmitted infections can be prevented with condoms, dental dams, and other barriers. If you share sexual toys consider using condoms/barriers or cleaning them between uses.

Consider using birth control methods if applicable. Testosterone is not an effective method of birth control. In fact, testosterone is bad for fetuses and masculinizes them too. Non-hormonal options for birth control include condoms, copper IUDs, diaphragms and spermicidal jellies.

If you’re under the age of 26, get the HPV vaccine. This will reduce the chance for cervical, vaginal, anal, and oral cancers.

Avoid tobacco, limit alcohol, and limit/avoid other drugs. If you choose to use substances and are unwilling to stop, consider strategies to limit your risk. For example, consider participating in a clean needle program. Vaporize instead of smoke. And use as little of the drug as you can.

Maintain a healthy weight. While being heavy sometimes helps to hide unwanted curves, it’s also associated with heart disease and a lower quality of life.

Exercise regularly. Anything that gets your heart rate up and gets you moving is good for your body and mind! Weight bearing exercise, like walking and running, is best for bone health.

Be careful when weight lifting if you’re newly taking testosterone. Muscles grow faster than tendon, thus tendons are at risk for damage when you’re lifting until they catch up.

Seek help if you’re struggling with self injury, anorexia, or bulimia. Trans men are at higher risk than cis men for these aspects of mental health.

If you have unexplained vaginal bleeding, are on testosterone, and have not had a hysterectomy notify your doctor immediately. Some “breakthrough” bleeding is expected in the first few months of testosterone treatment. Once your dose is stable and your body has adapted to the testosterone you should not be bleeding. Bleeding may be benign but it may also be a sign that something more serious is going on. Contact your doctor.

In addition, talk with your doctor if you have pain in the pelvic area that doesn’t go away. This may also need some investigation. And s/he may be able to help relieve the pain.

Be as gentle as you can with binding. Make sure you allow your chest to air out because the binding may weaken that skin and put you at risk for infection. Be especially careful if you have a history of lung disease or asthma because tight binding can make it harder to breathe. You may need your inhaler more frequently if you have asthma and you’re binding. If this is the case, talk with your doctor.

If you’ve had genital surgery and you’re all healed from surgery: there are no specific published recommendations for caring for yourself at this point. So keep in touch with your doctor as you need to. Call your surgeon if something specific to the surgery is concerning. Continue to practice safe sex. And enjoy!

Your doctor may wish to do other tests, including…

Cervical cancer screening (if you have a cervix). The recommendation is every 3-5 years minimum, starting at age 21. Even with testosterone, this exam should not be painful. Talk with your doctor about your needs and concerns. Your doctor may offer a self-administered test as an alternative. Not every doctor offers a self-administered test.

Mammography even if you’ve had chest reconstruction. We simply don’t know what the risk of breast cancer is after top surgery because breast tissue does remain after top surgery. Once you turn 50, consider talking with your doctor about the need for mammography. In addition, if you’re feeling dysphoric discussing breast cancer then it may be helpful to remember that cis men get breast cancer too.

If you have not had any bottom surgery you may be asked to take a pregnancy test. This may not be intended as a transphobic question. Some medications are extremely harmful to fetuses. Hence doctors often check whether someone who can become pregnant is pregnant before prescribing. Cisgender lesbians get this question too, even if they’ve never had contact with cisgender men.

And most importantly: Take care of your mental health. We lose far too many people every year to suicide. Perhaps worse, far more struggle with depression and anxiety. Do what you need to do to take care of you. If your normal strategies aren’t working then reach out. There is help.

Phalloplasty is one of two options for genital surgery for trans men. While it’s more expensive and extensive than the metoidioplasty, the additional size is often appreciated by the men who opt for it.

Suggestive flower is suggestive

Why would I want a phalloplasty?

Everyone has their own reasons. Here are some that I have heard:

Ability to “pass” in male spaces, such as bathrooms and locker rooms. With genital surgery, the fear of having a towel around the waist slip at an awkward moment is gone.

Relieving gender dysphoria. What’s not to like about that?

Ability to pee standing up. Only with a urethral lengthening procedure, which carries its own risks.

Having a large penis. It both clearly identifies you as male and allows for penetrative sex.

What is involved in phalloplasty? What are my options? And what different techniques are there?

Phalloplasty is one of the most complex genital surgeries, with a lot of different varieties. Phalloplasty is anywhere from 1 to 4 surgeries, and often includes these procedures:

Creation of a phallus. There are two basic techniques: either a pedicled flap or a free flap. Pedicled flaps are from nearby areas and remain attached to the body at all times. Free flaps can be from other areas of the body (common areas are the forearm and back) and are fully detached and then reattached. Here’s an NSFW diagram comparing the two. We’ll talk more on these in a moment…

Urethral lengthening. The inner labia, among other tissues, are used to lengthen the urethra so you can pee from the tip of the penis. Not all surgeons do this.

Vaginectomy and scrotoplasty with implants. The vaginal tissue is removed and may be used in urethral lengthening. The labia are stitched together to make a scrotum, which can then have testicular implants.

Hysterectomy and oophorectomy. Removal of the uterus, fallopian tubes, and ovaries.

Penile implant. An implant to allow for erection is inserted. This is an additional surgery after the original surgeries have well healed, often 9 months or more.

Glansoplasty. Refinement of the appearance of the head of the penis.

Different surgeons do these parts at different stages. Some surgeons don’t do certain techniques at all — I know of at least one surgeon who doesn’t do urethral lengthening in their phalloplasties.

Now, what about where the penis comes from? The tissue is typically “rolled up” to make a penis, no matter where it’s from. That’s an unflattering description, but it produces some fabulous results. As for the technique — they’re either a pedicle technique or a free flap technique. Pedicle techniques take tissue from the abdomen or inner thigh and rotate it into its final place. Pedicles have their original nerves and blood supply, so some say they have less erogenous sensation. Pedicles do have less visible scarring than free flap.

Free flap detaches tissue completely from its old location and attaches it using microsurgery to its new home as a penis. Sensation is often intact because of this microsurgery. The tissue is usually from the forearm, back, or inner thigh. Scarring can potentially be an issue.

Both techniques provide erogenous and non-erogenous sensation. Both can be used for penetrative sex and for urinating while standing. Both are considered aesthetically pleasing — it’s up to what you want and what your chosen surgeon recommends for you.

Can you tell me more about the surgery? Does it require full anesthesia? How long would I be in the hospital? What kind of recovery time am I looking at?

Phalloplasty is an intense surgery. All phalloplasties require full anesthesia. Pedicle generally requires less surgery time than free flap. I’ve seen hospital stays vary from 2-6 days, and initial recovery lasting 2-4 weeks. Return to work is often from 4-8 weeks depending on the surgery, your recovery, and how strenuous your work is.

For multiple stage phalloplasties, the first stage is often the longest and additional stages take less time and are less expensive.

What are the possible risks of phalloplasty?

The usual risks with surgery apply here: adverse drug reactions, bleeding, infection and the like. Permanent loss/reduction in sensation may occur, as with all surgeries. And pain can persist for a long time.

The penis itself can end up twisted (torqued), which is repairable by surgery. And rarely some or all of the tissue can become infected or even die.

Penile implants occasionally have complications. They can slowly erode through the penis or be associated with infection. These complications are rare with today’s techniques and implants.

Urethral lengthening caries its own risks, including urethral narrowing or blockage, and urethral fistula. Urethral fistula is when a hole forms between the urethra and somewhere it shouldn’t be — so urine may spray from the underside of the penis, for example. Narrowing, blockage, and fistula can be repaired surgically. The stream of urine may also spray or be not what you expect.

What about scars?

Pedicle techniques have less scarring than free flap. Free flap scars can be significant but aren’t always — it depends on how you heal.

How will phalloplasty affect my long-term health?

The phalloplasty itself doesn’t generally have long-term health implications unless there were complications. The same applies to the urethral lengthening.

Vaginectomy removes your risk for vaginal cancer. If you also had a hysterectomy/oophorectomy, you no longer are at risk for those cancers. However in order to maintain bone health it’s important to stay on sex hormones (testosterone) life-long.

Can I have penetrative sex with my partners after a phalloplasty?

If you have a penile implant, yes. A penile implant is required to achieve an erection.

Can I stand to urinate after a phalloplasty?

If you have a urethral lengthening procedure, yes.

What about the clitoris?

The clitoris can be buried at the base of the penis or tucked just underneath the penis. Either way, it can and does provide erogenous sensation.

Can I have a phalloplasty if I’ve already had a metoidioplasty?

Yes!

More information?

I am not a surgeon, nor an expert on surgeries! Check out some of these other resources and surgeon websites for more information:

The metoidioplasty is one of two potential genital surgeries for trans men. It takes advantage of the fact that trans men already have a penis: their clitoris!

With testosterone, the clitoris grows. A metoidioplasty removes tissue around the clitoris. This exposes more of it and helps it to hang in a more male position. That’s why a metoidoplasty is sometimes also called a “clitoral release” or a “free-up”. That’s it — that’s the core of a metoidioplasty.

In addition, the urethra can also be routed through the neopenis. At the same time the vagina can also be removed, and a scrotum made from the labia. A metoidioplasty does not remove the cervix, uterus, or ovaries. That would be a different surgery. However some surgeons will perform a hysterectomy at the same time as a metoidioplasty.

All in all, a metoidioplasty preserves the tissues that are already there. It shuffles them around into a masculine shape. Not everybody will have everything done, and there are many options.

Why would I want a metoidioplasty?

Everyone has their own reasons. Here are some that I have heard:

Ability to “pass” in male spaces, such as bathrooms and locker rooms. With genital surgery, the fear of having a towel around the waist slip at an awkward moment is gone.

Relieving gender dysphoria. What’s not to like about that?

Ability to pee standing up. Only with a urethral lengthening procedure, which carries its own risks.

Keeping erections and erogenous sensation. Some men are also able to have penetrative sex after a metoidioplasty.

Cheaper, easier to find a surgeon, and fewer surgeries than a phalloplasty with good results.

What is involved in metoidioplasty? What are my options?

Different surgeons will include different specific stages to a metoidioplasty. But the core of a metoidioplasty is clitoral release. The clitoris is freed from its surrounding tissues so it can hang the way a penis hangs.

Others steps are often included, including…

Vaginectomy: Removal of the vagina. May be required for some forms of urethral lengthening. Usually combined with a scrotoplasty, which fuses the labia together to make a scrotum. At the same time testicular implants can also be placed.

Urethral lengthening: The urethra is routed through the neopenis and lengthened using other tissue. This allows peeing through the penis and while standing.

Hysterectomy, oophorectomy: Removal of the uterus, fallopian tubes, and ovaries.

I’ve heard there are different techniques. What are they?

The biggest difference centers around urethral lengthening. Since the urethra is only so long, other tissue is used to lengthen it. That tissue can come from the vagina or inner labia, or it can come from the inside of your cheek (“buccal”).

Surgeons often have their own individual techniques and strategies in addition.

Can you tell me more about the surgery? Does it require full anesthesia? How long would I be in the hospital? What kind of recovery time am I looking at?

It depends on which specific procedures you have done.

For a simple metoidioplasty only without urethral lengthening, vaginectomy/scrotoplasty, or hysterectomy, some surgeons will perform it under “twilight” anesthesia. This is also called conscious sedation. You’ll be relaxed and won’t feel pain but will likely stay awake. This level of sedation is also used by some dentists, so it’s not unique to this procedure. If you’re also having more intense procedures, like urethral lengthening, then you’ll be under general anesthesia.

The surgery itself lasts anywhere from 2-5 hours depending on what procedures you’re having. You’ll likely spend one night in recovery in the hospital. Full recovery time also varies. One surgeon advises bed rest for 24 hours, plus either 7-14 days off work with no heavy lifting for 2-4 weeks. Again — this depends on the intensity of your surgery.

What are the possible risks of metoidioplasty?

The usual risks with surgery apply here: adverse drug reactions, bleeding, infection and the like. Permanent loss/reduction in sensation may occur, as with all surgeries. And pain can persist for a long time.

The penis itself can end up twisted (torqued), which is repairable by surgery. The length may also be less than was hoped.

Urethral lengthening caries its own risks, including urethral narrowing or blockage, and urethral fistula. Urethral fistula is when a hole forms between the urethra and somewhere it shouldn’t be — so urine may spray from the underside of the penis, for example. Narrowing, blockage, and fistula can be repaired surgically. The stream of urine may also spray or be not what you expect.

What about scars?

The beauty of metoidioplasty is that it doesn’t leave very visible scars.

How will metoidioplasty affect my long-term health?

The metoidioplasty itself (the clitoral extension) doesn’t generally have long-term health implications unless there were complications. The same applies to the urethral lengthening.

Vaginectomy removes your risk for vaginal cancer. If you also had a hysterectomy/oophorectomy, you no longer are at risk for those cancers. However in order to maintain bone health it’s important to stay on sex hormones (testosterone) life-long.

Can I have penetrative sex with my partners after a metoidioplasty?

It depends, but the answer is definitely not “no”. Different people have different results, and different surgeons have different results too. Some surgeons report 4-6cm (1.6-2.4″) long penises, others boast 6-12cm (2.4-4.7″).

If being able to penetrate a partner is the most important thing for you, then you might want to consider a phalloplasty.

More information?

I am not a surgeon, nor an expert on surgeries! Check out some of these other resources and surgeon websites for more information:

The science of transgender is still in its infancy, but evidence so far points to it being biological. Differences in brain have been seen, and I’ve covered them before here on OMH. However, genetic evidence is also being published! This week, let’s take a look at CYP17. CYP17 is a gene that makes enzymes that are part of sex hormone synthesis. Mutations in CYP17 have been noted in some intersex conditions, such as adrenal hyperplasia.

Now, there’s a SNP that’s been noticed in CYP17. SNPs are “single nucleotide polymorphisms”, which takes some explaining. SNPs are very, very tiny mutations in genes — just one letter in the DNA alphabet changes! SNPs don’t usually change the protein that the gene makes very much.

So we have this gene — CYP17, that is involved in making sex hormones. And we have this tiny mutation, this SNP. Now let’s look at the science!

Specifically, let’s look at this one study that was published back in 2008. They looked at the CYP17 gene in 102 trans women, 49 trans men, 756 cis men, and 915 cis women. They compared the CYP17 of trans women to cis men, and trans men to cis women. Unlike many studies, this comparison makes sense. We’re talking about the DNA in the genes here, not something that’s changed by hormonal status.

They found multiple things:

There was no difference between trans women and cis men

Trans men were more likely to have a SNP in their CYP17 than cis women were.

Cis men, trans women, and trans men all had the SNP more frequently than cis women

What does that mean?

We don’t know yet. But it does appear that CYP17 is a gene that it might be worth looking deeper into to find potential causes for transgender.

The Greek letter Psy is often used to symbolize psychology or the APA.

The American Psychological Association has released a 55-page document detailing guidelines for psychologists treating transgender and gender non-conforming individuals. To my knowledge, this is the first such document the APA has published. It’s a huge milestone in trans mental health care.

APA guidelines provide standards for both trainees and practicing psychologists on the expected conduct of psychologists. They’re used in both introductory and continuing education.

In this document, the APA lists out the following guidelines (note that TGNC stands for “transgender/gender non-conforming”):

Psychologists understand that gender is a non‐binary construct that allows for a range of gender identities and that a person’s gender identity may not align with sex assigned at birth.

Psychologists understand that gender identity and sexual orientation are distinct but interrelated constructs.

Psychologists seek to understand how gender identity intersects with the other cultural identities of TGNC people.

Psychologists are aware of how their attitudes about and knowledge of gender identity and gender expression may affect the quality of care they provide to TGNC people and their families.

Psychologists recognize how stigma, prejudice, discrimination, and violence affect the health and well‐being of TGNC people.

Psychologists strive to recognize the influence of institutional barriers on the lives of TGNC people and to assist in developing TGNC‐affirmative environments.

Psychologists understand the need to promote social change that reduces the negative effects of stigma on the health and well‐being of TGNC people.

Psychologists working with gender questioning and TGNC youth understand the different developmental needs of children and adolescents and that not all youth will persist in a TGNC identity into adulthood.

Psychologists strive to understand both the particular challenges that TGNC elders experience and the resilience they can develop.

Psychologists recognize that TGNC people are more likely to experience positive life outcomes when they receive social support or trans‐affirmative care.

Psychologists strive to understand the effects that changes in gender identity and gender expression have on the romantic and sexual relationships of TGNC people.

Psychologists seek to understand how parenting and family formation among TGNC people take a variety of forms.

Psychologists recognize the potential benefits of an interdisciplinary approach when providing care to TGNC people and strive to work collaboratively with other providers.

Psychologists respect the welfare and rights of TGNC participants in research and strive to represent results accurately and avoid misuse or misrepresentation of findings.

Psychologists seek to prepare trainees in psychology to work competently with TGNC people.

This is all excellent.

There is a history of psychologists attempting to change gender identity through conversion therapy or other coercive means. The APA’s statement, in effect, states very strongly that attempts to change gender identity should not be attempted. Instead, the APA is embracing the ethical treatment of transgender people and of affirming transgender and gender non-conforming people.

Do these guidelines mean anything for you if you’re receiving therapy? Possibly. Talk with your therapist, whether you’re trans or cis, to make sure they’ve seen the updated guidelines. If you’re receiving therapy that is not within these guidelines, consider talking with your therapist about these guidelines or seeking another therapist.

What is Open Minded Health?

OMH is dedicated to providing information about gender and sexual minority health. Posts are a mix of the latest research, activity risk reduction tips, and the latest news.

This blog is definitely not suitable for children, and probably not work safe. It contains descriptions of sexual activities that may disturb some readers.

Also please be aware: I am not a doctor. OMH does not provide health care advice - the information here is to be used as information only. It does not substitute a visit to your health care provider. When in doubt, please ask your health care provider.

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